The present invention relates to Workers' Compensation information processing systems.
Workers' compensation is a class of insurance mandated by States and the federal government whereby employers provide employees with medical and disability benefits for injuries or illness incurred in the course and scope of their employment. Unlike other classes of insurance, workers' compensation insurance does not require written documentation that identifies individual covered employees.
Workers' compensation insurance obtained from an insurer, or which is financed by the employer (self-insurance), is based upon underwriting criteria that includes payroll, number of employees, job classifications, aggregated loss experience(non-personal) and actuarial modifiers. Insurers and self-insurers—payers—typically do not maintain lists of covered employees.
For this reason, when an employee incurs an injury or illness and seeks treatment, matching the claim to the payer responsible for payment is difficult. Typically neither the injured employee nor the medical provider knows or has access to the Workers' compensation claim identifier the payer requires to make a payment for medical services rendered. Identity of the payer typically also is not known. This leads to delays in claim administration, poor coordination of treatment between the payer and the provider (often to the detriment of the injured employee) and untimely payment for medical services rendered.
When the work-related injury or illness occurs, the employer must report the occurrence to the payer (insurer, self-insurer, or third-party administrator), who then creates a claim file with a specific claim number. All subsequent communications and transactions depend on, are routed and administered according to this claim number. The claim number is essential to efficient operation of a workers' compensation system. The claim number is the payer's key identifier for file management, work flow routing, document matching, date capture and payment transactions. In order to receive prompt payment, a medical provider must provide the claim number when submitting bills and reports. It is often the case that the provider has no knowledge of or access to the claim number.
Providers such as physicians and pharmacists will often send bills without the claim number because a claim number has not been assigned, or because of the administrative difficulties of obtaining the claim number. Bills without the claim numbers produce a substantial burden of unmatched mail for the payer.
One Workers' Compensation industry survey has indicated that as many as fifty percent of provider bills, reports and attachments are received by the payer without claim numbers. Fifty percent of this number, or twenty-five percent of the total, typically do not match any injury within the payer's claim system. Bills lacking claim numbers cause a great deal of difficulty for the payer's bill verification systems, rendering them slow, duplicative, prone to error, and costly to administer.
In the current typical Workers' Compensation payment system, the process of producing claim numbers is often protracted. For example, the employer may not report the Workers' Compensation claim for a relatively long period of time and thus no claim number is set up, even though the injured worker has sought and received medical treatment. Thus, when the injured party goes to the provider, the provider is unable to find a claim number and has no choice but to produce a bill without the required claim number. This bill can take some time working its way through the payer's system. Later the employer is prompted by the payer to report the claim.
In addition, when the payer's recognition of medical treatment of an injured worker is delayed because a claim number has not been matched to the medical bill or report, the report of injury by the employer, prompted by the payer, is typically delayed. Slow reporting by the employer delays medical management by the payer and increases the cost of the claim. For example, in one study by a major Workers' Compensation insurer, the costs of a claim decreased three percent for each day that reporting was shortened between 21 to 7 days. Another large Workers' Compensation insurer found that claims reported within 10 days were 47% less costly than those reported in 31 days.
It is desired to produce an improved Workers' Compensation information processing system.